Health Information Management

Differentiate between types of wound debridement

JustCoding News: Outpatient, August 8, 2012

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A physician can debride a wound to remove dead, damaged, or infected tissue so the remaining healthy tissue can better heal. Coders need to look for specific information in the documentation of wound debridement.

The AMA made major revisions to the wound care CPT® codes in 2011 to make them more encompassing, says John David Rosdeutscher, MD, a plastic surgeon with Cumberland Plastic Surgery in Nashville.
 
 
Types of debridement
Debridements are classified as:
  • Excisional
  • Selective
  • Non-selective
Each type has its own code or series of codes in CPT.
 
 
 
Excisional debridement is the sharp removal of tissue at the wound margin or at the wound base until viable tissue is removed. Coders report excisional debridement codes (CPT codes 11042-11047) based on the deepest layer of viable tissue removed, Rosdeutscher says.
 
The codes for excisional debridement are divided by the level of tissue removed and the size of the wound debrided, says Gloria Miller, CPC, CPMA, vice president of reimbursement services for Comprehensive Healthcare Solutions, Inc., in Tacoma, Wash. If the physician removes only subcutaneous tissue, coders would report CPT code 11042 for the first 20 sq cm and 11045 for each additional 20 sq cm. So if the physician documents removal of 65 sq cm of subcutaneous tissue, ­coders would report 11042 and 11045x3.
 
For debridement of muscle or fascia, coders ­report 11043 for the first 20 sq cm and 11046 for every ­additional 20 sq cm. If the physician debrides a wound down to the bone, report 11044 for the first 20 sq cm and 11047 for each additional 20 sq cm. Note that the ­add-on codes for additional sq cm do not directly follow the codes for the first 20 sq cm, Miller says.
 
Selective debridement (CPT codes 97597-97598) is the removal of nonviable tissue. Unlike excisional debridement, the physician removes no living tissue in a selective debridement.
 
Non-selective debridement (CPT code 97602) is the gradual removal of nonviable tissue and is generally not performed by a physician, Rosdeutscher says.
 
Total area removed
When coding multiple debridements on the same level, such as three subcutaneous debridements, coders should total the surface area debrided and select the appropriate codes, Miller says.
 
For example, a physician documents a 26 sq cm debridement to the muscle of the upper right arm, a 15 sq cm debridement to the muscle of the right shoulder, and a 16 sq cm debridement to the muscle of the lower right arm. The coder would add all three areas together for a total of 57 sq cm and report 11043 for the first 20 sq cm and 11046x2 for the remaining 37 sq cm.
 
If the physician documents debridements to ­different levels at the same anatomical site, report only the deepest debridement, Rosdeutscher says. If the physician documents different levels of debridement at different anatomical sites, coders should report both debridements and append modifier -59 (distinct procedural service) to the shallower debridement, he adds.
 
For example, the physician documents a 14 sq cm debridement to the bone on the patient's left leg and a 35 sq cm subcutaneous debridement of the patient's left arm. Coders would report 11044 for the left leg debridement and 11043-59 and 11046-59 for the left arm.
 
Remember as well that coding is based on the surface area after the debridement, Rosdeutscher says. ­Coders should look for documentation of the type of tissue removed and whether the wound is larger, Miller adds. This will help them decide whether to bill excisional codes or removal of nonviable tissue codes. For an excisional debridement, the post-debridement wound size should always be larger because the physician is removing living tissue.
 
Selective debridement
Miller says coders cannot report an excisional debridement if the debridement does not include at least one of the following:
  • Bleeding tissue
  • Removal of viable tissue
  • Increasing wound size by width, length, or depth
In cases that don't meet any of the above criteria, ­coders may assign an E/M visit level, removal of devitalized tissue, or a non-selective debridement.
The removal of devitalized tissue is called selective debridement or active wound management, Miller says. Coders should only report these codes once per visit, ­regardless of how many wounds are debrided. These codes are only used when a provider removes nonviable tissue, and coders should not see documentation of bleeding (which indicates living tissue), Miller says.
Documentation for selective debridement must include the following elements:
  • Location and characteristic of lesion
  • Depth (should be minimal)
  • Type of tissue removed (nonviable)
  • Instrument used (can be sharp)
  • Patient's tolerance
  • Dressings applied and treatment plan
Case example
Miller provides the following case example to illustrate what a coder should look for in the documentation of a wound care visit:

A 72-year-old male patient presented to the hospital for his first visit for E/M of bilateral venous ulcers, left/right legs. This patient had been previously treated at the hospital within the last three years.  A history was completed, an examination was performed, and the decision was made to perform debridement. The patient was advised of the treatment and consent was obtained. A photo of the ulcers was taken before and after treatment.
The areas for debridement were prepped and cleansed. A scalpel was used to debride subcutaneous devitalized tissue on the right and left leg ulcers (different sites). Total ulcer measurements were 25 sq cm. Some bleeding occurred and pressure was applied. Each ulcer was dressed with multi-layered compression wraps. The patient tolerated the procedures well. Instructions were provided to the family, and the patient is to return in three days.
 
What should the coder assign? Start by determining the E/M visit level, Miller says. Based on the facility's point system, this patient meets the criteria for a level 3 (established patient) E/M visit. Other facilities might assign a different E/M level based on their specific criteria. ­Coders will need to add modifier -25 (significant, ­separately ­identifiable evaluation and management service was provided by the same physician on the same day as another procedure or other service) to the E/M visit code.
 
Report the excisional debridement with codes 11042 and 11045. The facility cannot separately bill for the compression wraps because the provider debrided the wound, Miller says. However, the coder should report the HCPCS codes for the supply of the compression wraps to the patient's bill, she adds.
The final code selection would be:
  • 99213-25
  • 11042
  • 11045 x1
  • Compression wrap supply HCPCS code x 2
Be sure to check with your local FI/MAC for any ­local coverage determinations or specific documentation requirements for wound care.
 
 
Documenting excisional debridement
Need a quick checklist for excisional wound debridement? Millerprovided these nine items that coders should look for when coding for an excisional debridement:
1. Medical decision to perform procedure
2. Location and characteristics of wound
3. Type of tissue removed (eschar, fibrin, bone, etc.)
4. Depth of procedure
5. Amount of bleeding and how it was stopped
6. Instrument used and size of instrument
7. Patient tolerance and pain control
8. Dressing applied and treatment follow-up
9. Pre- and post-debridement measurements 
Remember that if the physician performs a subcutaneous, muscle, or bone debridement, the wound measurements should be larger post-debridement.
 
Editor’s note: This article was originally published in the July issue of Briefings on APCs. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.



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